Exam 3: Cough

Question 1

Cough: Mechanical stimulus

Answer 1

Mucus or nasal drippings down throat

Question 2

Cough: Chemical stimulus

Answer 2

Breathing in chemicals in the air (teargas, cigarette smoke, etc.)

Question 3

Cough: Physiology

Answer 3

Vagus and superior laryngeal nerves to cough center in brainstem, leads to complex series of involuntary muscular actions (cough reflex)

Question 4

Cough: Causes

Answer 4

Common cold, viral infxn, pulmonary embolism, pneumonia, post nasal drip/upper airway cough syndrome (UACS), asthma, bronchitis, GERD, CHF, Meds (ACEI/BB)

Question 5

Cough categories: Duration: Acute

Answer 5

≤3 weeks
Usually attributed to upper respiratory tract infection or cold
Only type of cough that should be self-treated OTC

Question 6

Cough categories: Duration: Sub-acute

Answer 6

3-8 weeks

Question 7

Cough categories: Duration: Chronic

Answer 7

≥8 weeks

Usually attributed to many things: meds, asthma, COPD, GERD

Question 8

Cough categories: productivity: productive vs non-productive

Answer 8

Productive: produces phlegm/mucus/sputum

Non-productive: dry cough

Question 9

Cough categories: Effectiveness: Effective vs Ineffective cough

Answer 9

Effective: successfully clears airway of phlegm/mucus/sputum
Ineffective: does not successfully clear airway

Question 10

Upper Airway Cough Syndrome (UACS) formerly known as ___

Answer 10

Post-nasal drip syndrome

Question 11

Upper Airway Cough Syndrome (UACS) def

Answer 11

Situation where a productive or nonproductive cough is associated with other upper respiratory symptoms such as nasal congestion, runny nose, tickle in throat, throat clearing
Nasal secretions drip and irritate throat and produce cough

Pt may not make association bt cough/nasal sx

**Often more at night when pt is laying down

Question 12

Complications of untreated cough

Answer 12

Exhaustion
Insomnia
Musculoskeletal pain
Hoarseness
Excessive perspiration
Urinary incontinence

Question 13

Cough Treatment Goals

Answer 13

Reduce freq and severity of cough episodes

Prevent complications

Question 14

Cough Self-care Exclusions

Answer 14

Cough with any of: chest pain, chills, cyanosis, fever, hemoptysis, lower extremity edema, night sweats, persistent headache, rash, SOB, throat tightness, unintended weight loss

Duration >7 days
Foreign object inhalation/aspiration
H/o cough associated with asthma/COPD
Drug associated cough
worsens/develops new symptoms during self-treatment

Question 15

Cough Non-Pharm Treatment

Answer 15

Adequate hydration/fluids
Vaporizers and humidifiers
Non-medicated cough drops, lozenges, hard candies
Honey (1/2-1tsp prn, increases saliva prod and reduces irritation, caution for DM pts)

Question 16

There is evidence honey is just as good as ____

Answer 16

Dextromethorphan

Question 17

Cough Treatment Options: Step 1

Answer 17

Identify type of cough: non-productive/productive, UACS

Question 18

Cough Treatment Options: Step 2

Answer 18

Select approrpaite agent based on type of cough and pt-specific factors

Question 19

Cough Treatment Options: Step 3

Answer 19

Select appropriate dosage form

• Infants/young children: liquid suspensions (shake before use)
• Children >4yo: chewable/meltaway tabs
• adults: regular or ER tabs

Question 20

Nonproductive Cough Treatment: 3 Options

Answer 20

OTC Oral antitussives, OTC topical antitussives, Rx Oral antitussives

Question 21

OTC Oral antitussives examples

Answer 21

Codeine

Dextromethorphan (Delsym, Robitussin)

Question 22

OTC oral antitussives: Codeine: MOA

Answer 22

Opioid agonist, centrally acting (increases threshold for cough reflex in cough center

Question 23

OTC oral antitussives: Dextromethorphan: MOA

Answer 23

NMDA antagonist, centrally acting (increases threshold for cough reflex in cough center)

Question 24

OTC oral antitussives: ADE/DDI

Answer 24

ADE: may cause CNS depression, N/V, drowsiness
DDI: MOAis

Question 25

OTC Topical antitussives examples

Answer 25

Camphor (Vicks VapoRub, Vicks VapoSteam)

Menthol (cough drops)

Question 26

OTC Topical Antitussives: MOA

Answer 26

Counter irritant

• provide low grade stimulation of nerves in throat cell > prevents triggering of larger stimulation that causes cough
• work like anesthetic > can make airways feel more open and breathe clearer

Question 27

OTC topical antitussives: ADE

Answer 27

Irritation/burning of eyes/nose/skin

Camphor: toxic if ingested, topical use only

Question 28

Rx oral antitussives examples

Answer 28

Hydrocodone/chlorpheniramine (Tussionex)

Benzonatate (Tessalon)

Question 29

Rx oral antitussives: Hydrocodone/chlorpheniramine: MOA

Answer 29

opioid agonist/antihistamine

Question 30

Rx oral antitussives: Benzonatate: MOA

Answer 30

Anesthetizes stretch receptors in airways to suppress cough reflex

Question 31

Rx oral antitussives: Hydrocodone/chlorpheniramine: ADE/DDI

Answer 31

Sedation, dizziness, dry mouth, constipation, N/V

CI: MAOis
Caution with other serotonergic agents and/or CNS depressants

Question 32

Rx oral antitussives: Benzonatate: ADE/DDI

Answer 32

Hypersensitivity rxn (avoid in pts with allergy to local anesthetics)

No DDI

Swallow capsule whole (don’t break or chew)

Question 33

Productive cough treatment options

Answer 33

Guaifenesin (Mucinex, Robitussin)

Drink Water

Question 34

Guaifenesin: MOA

Answer 34

Expectorant/protussive; incorporates water into mucus, increasing volume, and changing consistency (thinner)

Question 35

Guaifenesin: ADE/DDI

Answer 35

Rare but may include: dizziness, headache, diarrhea, N/V
Very high doses may causes kidney stones
No DDI

Question 36

UACS: Treatment

Answer 36

Decongestants + 1st gen antihistamines

*decongestants alone not effective, best when combo

Question 37

1st gen antihistamines examples

Answer 37

Bropheniramine (Dimetapp)
Chlorpheniramine (Chlor-Trimeton)
Diphenhydramine (Benadryl)
Doxylamine (Unisom)

Question 38

Brompheniramine Brand

Answer 38

Dimetapp

Question 39

Chlorpheniramine Brand

Answer 39

Chlor-Trimeton

Question 40

Diphenhydramine Brand

Answer 40

Benadryl

Question 41

Doxylamine brand

Answer 41

Unisom

Question 42

1st gen antihistamines MOA

Answer 42

Antagonist at central and peripheral H1 receptors (readily cross BBB) as well as antagonist at cholinergic receptors

Cough relief most likely due to anticholinergic effects that dry out nasal secretions and reduce post-nasal drip

Question 43

1st Gen Antihistamines ADE/DDI

Answer 43

Drowsiness (or possible excitability in children), CNS depression, respiratory depression, tachycardia, anticholinergic effects (blurry vision, urinary retention, dry mouth, dry eyes, CNS impairment: sedation, confusion, delirium, can mimic dementia)

*Beers for geriatrics, children may have paradoxical hyperactivity

DDI: avoid use with MAOi, additive CNS depression possible with sedative agents and other antihistamines

Will prevent reactivity of skin testing - d/c 4-10 days prior to test

Question 44

Spec pop considerations: Pregnant

Answer 44

Recommend non-pharm and refer to OB
Avoid codeine: birth defects possible in 1st trimester
Dextromethorphan is considered “probably safe”

Question 45

Spec pop consideration: Breastfeeding

Answer 45

Recommend non-pharm and refer to OB
Codeine is excreted in breast milk and may cause sedation in infants
Diphenhydramine can reduce milk supply and may cause sedation in infants
Unknown if dextromethorphan or guaifenesin are excreted in breast milk

Question 46

Spec pop considerations: Peds

Answer 46

Do not use cough and cold products in children <4 yo
Avoid opioid products in pts <18yo
May experience paradoxical excitation with antihistamines

Question 47

Spec pop considerations: Geriatrics

Answer 47

If used, use lowest dose possible
More likely to experience dizziness and sedation
1st gen antihistamines → Beers Criteria